Care Home: Linden Lodge

What the care home does well The manager and staff team know the people living in the home very well. The manager and staff team are working hard to meet the requirements made by the commission. This will improve the quality of care provided to the people living in the home. What has improved since the last inspection? People`s care plans were complete and up to date. One specific person now has their past history documented in their specific care plan. This ensures that clear information is available to the staff working in the home. People are now undertaking key worker sessions as agreed in their care plans which ensures people have the opportunity to discuss any issues that are important to them in improving the quality of care provided.The risk assessments have improved greatly and are being kept up-to-date. This ensures that any identified risks to people`s health and safety are minimised. This promotes the health and safety of the people living and working in the home. The Person living in the home that has complex behavioural needs and can be challenging has guidelines in place. This ensures that clear guidance is available to staff and improves the quality of care provided to the person living in the home. There have been a number of environmental improvements in the home. Further improvements are planned. This has improved the quality of life for the people living in the home. The manager has made her application for registration and is now the registered manager of the home. This will assist the staff team to work with the people living in the home in a consistent way and provide the home with clear direction. The manager has started to take action to promote advocacy services, which was a recommendation made at the previous inspection. This indicates that the manager takes the inspection process seriously. What the care home could do better: One person needs a risk assessment to be developed in relation to them attempting to go out into the community without the support of staff members. This will minimise the risks this poses to this person and promote their health and safety. All activities must be clearly recorded. This must also include the times when the people living in the home have refused an activity. The record needs to evidence the action staff have taken to try to engage the person in the activity. This will assist the manager to clearly monitor the range of activities people are undertaking. We recommend that the record of contact visits that people have with their family and friends is recorded on a contact sheet rather than on the daily log.This will assist the manager to monitor the level of contact actually undertaken by the people living in the home with their friends and family. The list of staff that are qualified to administer medication must be updated. This will ensure that the health and safety of the people living in the home is promoted and protected. We have requested that the manager and line manager take action to tighten the financial records to prevent and future minor recording errors. CARE HOME ADULTS 18-65 Linden Lodge 38a Linden Way Southgate London N14 4LU Lead Inspector Wendy Heal Unannounced Inspection 19th June 2008 10:45a Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Linden Lodge Address 38a Linden Way Southgate London N14 4LU 020 8447 9195 020 8447 9195 linden.lodge@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anne-Marie Holliday Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of service users accommodated to not exceed 8 in Linden Lodge, 38a Linden Way and 3 at 38 Linden Way. One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 28th June 2007 Date of last inspection Brief Description of the Service: Linden Lodge is owned by Parkcare Homes Ltd. The home provides care for up to 10 people with mental health needs. Linden Lodge consists of two adjoining houses and is situated in a pleasant residential area of Southgate. The home is close to local shops and facilities and is near to public transport routes. 38 Linden Way has 3 bedrooms, each with en-suite facilities. There is a lounge and kitchen on the ground floor and a room upstairs for staff where they sleep in at night. 38a has 7 bedrooms, each with a hand basin. There is also a lounge and kitchen/dining room, bathroom and an office used by staff. There is an attractive garden at the rear with a patio area. People living at the home have their own bedroom. The staff team consists of a manager, one deputy, senior support workers and support workers. A minimum of 2 care staff are on duty in the daytime and 2 sleep in at night. People take part in a variety of activities, both within and outside of the home. The Purpose and Function Document and the last Inspection Report are on the homes notice board for interested parties to view. The organisations fees are approximately £800.00 per person. This report is also accessible on the CSCI website. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is (2 stars good.) This means that people who use the service receive good outcomes. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took approximately 9 hours. The inspection started at 10:45 am and finished at 7:30 p.m. We undertook a tour of the building spoke with the people who live in the home and members of the staff team. We gained further information from the Annual Quality Assessment form, by an inspection of the documents kept in the home, including care plans and health and safety documentation. The manager offered her assistance throughout the period of the inspection. We would like to thank the people who use the service and the manager and staff team for their openness and participation. What the service does well: What has improved since the last inspection? People’s care plans were complete and up to date. One specific person now has their past history documented in their specific care plan. This ensures that clear information is available to the staff working in the home. People are now undertaking key worker sessions as agreed in their care plans which ensures people have the opportunity to discuss any issues that are important to them in improving the quality of care provided. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 6 The risk assessments have improved greatly and are being kept up-to-date. This ensures that any identified risks to people’s health and safety are minimised. This promotes the health and safety of the people living and working in the home. The Person living in the home that has complex behavioural needs and can be challenging has guidelines in place. This ensures that clear guidance is available to staff and improves the quality of care provided to the person living in the home. There have been a number of environmental improvements in the home. Further improvements are planned. This has improved the quality of life for the people living in the home. The manager has made her application for registration and is now the registered manager of the home. This will assist the staff team to work with the people living in the home in a consistent way and provide the home with clear direction. The manager has started to take action to promote advocacy services, which was a recommendation made at the previous inspection. This indicates that the manager takes the inspection process seriously. What they could do better: One person needs a risk assessment to be developed in relation to them attempting to go out into the community without the support of staff members. This will minimise the risks this poses to this person and promote their health and safety. All activities must be clearly recorded. This must also include the times when the people living in the home have refused an activity. The record needs to evidence the action staff have taken to try to engage the person in the activity. This will assist the manager to clearly monitor the range of activities people are undertaking. We recommend that the record of contact visits that people have with their family and friends is recorded on a contact sheet rather than on the daily log. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 7 This will assist the manager to monitor the level of contact actually undertaken by the people living in the home with their friends and family. The list of staff that are qualified to administer medication must be updated. This will ensure that the health and safety of the people living in the home is promoted and protected. We have requested that the manager and line manager take action to tighten the financial records to prevent and future minor recording errors. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, People who experience the service receive a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People do have the information they need to make an informed choice about were they want to live as a service user guide is available. People’s aspirations and needs are assessed prior to them moving into the home. EVIDENCE: We looked at the homes statement of purpose, which is up-to-date. This ensures that accurate information is available in relation to the document about the service for those people who need to use it. There is a service user guide, which the manager is in the final stages of updating. This document is kept in each person’s individual folder. This means it is accessible to all of the people who may need to read it. There have been two new admissions to the home since the previous inspection. Appropriate assessment information was available in people’s individual files based on their daily living skills, which ensures that adequate information is available to ensure their individual needs can be met. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People are receiving care in a way they prefer and require. The care plans seen are being reviewed and kept up-to-date. The service does support people to take risks as part of an independent lifestyle but further improvement needs to be made in relation to one specific risk assessment, which relates to the risk of one person going out in the community without staff support. EVIDENCE: People are receiving care in a way they prefer and require. The care plans are person centred which means they are more specific to people’s needs. They cover areas such as personal history, relationships, social inclusion, health, personal care, every day living skills and religion. The care plans are being reviewed and updated. Key worker meetings are taking place or noted as refused and a new date recorded on the person’s individual file as specified in people’s care plans. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 11 Risk assessments have been developed to minimise the identified risks to the people living and working in the home. The risk assessments covered include sexually inappropriate behaviour towards female members of staff, suicide and self -harm, false accusations towards staff, substance misuse, non- compliance with medication, and depression. The manager has also completed new risk assessments in relation to a person who has recently been accommodated at the home. These include the risk of slips trips and falls, the risks associated with the person smoking in their bedroom and not in the allocated smoking room. Vacating the home in the event of a fire- taking place at the home. This safeguards the person’s health and wellbeing. The fire risk assessment has also been reviewed as a result of this person’s specific needs. This ensures the persons health and safety is promoted and protected. One specific person who has on one occasion left the home with another person from the home without the knowledge of staff but this person did not have a risk assessment completed in relation to this. The manager has informed me that this has been completed at the time of writing this report. We were pleased to see clear information that had been sourced by the manager in relation to alcohol addiction, depression, advocacy and the support services available, which were available in people’s individual files. This ensures that people are provided with information in relation to their specific needs, which, further empowers them. This was a recommendation made at the previous inspection, which the manager has acted upon. This indicates that the manager takes the inspection process seriously. There are clear behaviour guidelines in place. One person’s guidelines need to be dated. It should also be evidenced on file that the appropriate professionals have also seen and are in agreement with the guidelines in place. This will ensure that professional practice is being followed. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People are part of the local community, which enriches their lives. People are assisted to maintain appropriate relationships, which assists their emotional wellbeing. Consistent recording of activities does not always take place. People are offered a healthy diet, which promotes their good health. EVIDENCE: None of the ten people living in the home attend college courses. Two people attend structured sessions, which include arts and craft and every day living skills sessions. On the day of the inspection three of the people living in the home and a member of the staff team went bowling and then had their lunch out in the community. People’s activity records were inspected and it was recorded that staff had supported people to undertake activities in the community, such as bowling, dinner out, attending the fun fair, shopping, swimming, baking cakes, Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 13 undertaking games such as picture bingo. This increases people’s independence and social interaction. However not all activities undertaken were sufficiently recorded on the activity records to indicate the full range of activities undertaken. Staff also need to record when they have tried to engage people in an activity that has been refused. Six of the people living in the home are going on holiday to Caster in August 2008. A number of people do not wish to go away but are going to go on day trips out. This provides people with the chance to experience new opportunities. A number of the people living in the home have contact with their relatives. This benefits their emotional wellbeing. This information is recorded on the daily recording sheet. We recommend that he contact visits need to be recorded on a separate recording sheet. This will assist the manager to keep a more effective record of the actual contact visits undertaken by people with their friends and family. People living in the home do have a key to their bedroom, which they are able and choose to use. Staff do knock on people’s bedroom doors when they enter people’s bedrooms. This ensures people’s rights are respected. The kitchen was clean and tidy, which promotes people’s health and wellbeing. The fridge freezer was inspected and all food was within its use by date and properly labelled which ensures that people are not eating food that is harmful to their health. The menu of food available was wholesome and nutritious. This ensures people’s dietary needs are being met. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People’s physical and emotional health care needs are being met. The process for recording and administering medication is effective which promotes good health. EVIDENCE: The record of people’s health care appointments for each person was inspected. We found documented evidence to indicate that people are being supported to receive all of their individual healthcare checks. This means that people’s health care needs are being fully monitored. Information is being recorded. However the information recorded in relation to health care appointments needs to be more explicit in some instances in relation to the reason for the visit and the outcomes of the visit. The manger has stated that she will act on this. Given the positive action taken by the manager since the previous inspection a requirement has not been made. The records of people’s weight monitoring charts were being kept up-to-date. This means that people’s weight monitoring programme is being effectively monitored. This benefits people’s health and wellbeing. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 15 The medication and administration records were inspected and all medication had been signed for on the medication administration record. This means that professional procedures are being followed. The medication cupboard was inspected and found to be in order. This safeguards people’s health and wellbeing. The list of staff that have been trained to administer medication needs to be updated. This will ensure that up to date information is available in the home in relation to who can administer medication and ensure professional practice is promoted. People were appropriately dressed at the time of the inspection. This promotes people’s self-esteem. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People who are living in the home can be confident their views are listened to and acted upon since the recording and action taken in relation to complaints was found to be in order. Staff have had training and have the information available to protect people living in the home from potential abuse neglect and self-harm. EVIDENCE: We examined the complaints procedure and one complaint had been made since the previous inspection. This complaint had been sent directly to the organisations head office. The area manager had appropriately responded to this complaint. People living in the home have a copy of the complaints procedure in their bedrooms in their individual file. A copy of the homes complaints procedure is also available on the homes notice board in the hall. This ensures that the document is accessible to all of the people who may wish to view it. The organisations whistle blowing procedure was seen and was found to be in order. This ensures that people have the necessary information to report any concerns in relation to professional practice within the home. This will benefit the wellbeing of the people living and working in the home. There was document information in each persons file in relation advocacy and what it was. The manager had obtained this information from a mental health organisations website. The manger is building on this information in an Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 17 attempt to assist the people living in the home to have additional information available to them to assist them if they wish to make a complaint. The adult protection guidelines for the organisation were available. The adult protection procedures in relation to the relevant placing authorities were also available. This means that staff are provided with the information they need to protect them from potential abuse. Staff had undertaken adult protection training. This ensures that the staff’s knowledge and skills are being kept up-to-date and assists staff to further protect people from potential abuse. People’s financial records were inspected. Two of the ten identified people living in the home had extra money in their account compared with the total recorded. We discussed this with the manager and the area manager and they are going to discuss the financial recording system to agree how the recording system can be tightened. This will ensure that the financial recording system is fully effective and protects the people living in the home from any potential financial abuse. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30, People living in the home experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have benefited from recent improvements regarding the environment. People are living in a clean safe environment. EVIDENCE: Linden Lodge is located in a residential area near to local shops and public transport. We completed a tour of the home with the assistance of the registered manager. We inspected the premises and people’s bedrooms having sought their permission. Since the previous inspection some environmental improvements have taken place. There is now a new table and chairs in the kitchen. This ensures that people can sit down and eat their meal in comfort. The microwave has been replaced. This means that people have all of the equipment they need to live as independently as possible. On the day of the inspection the kitchen was clean and tidy. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 19 The manager and area manager confirmed during a conversation on the day of the inspection that the kitchen cupboards, kitchen - work- top and kitchen flooring is due to be replaced in the main house. This will make the home a nicer place for people to live. This work is due to commence in September 2008. One identified person’s bedroom cabinet, which was broken, has now been replaced. This ensures that the person has been provided with all of the furniture in their bedroom that they need to be comfortable. One person who has recently moved into the home has moved into a newly decorated bedroom. This bedroom also has a new bed, curtains and new wooden - flooring. This bedroom also has an en suite shower. The bedroom and shower have been fitted with suitable aids to improve the person’s independence as a result of their individual OT assessment. The manager is in the process of putting up shelving and improving the storage facilities for this person as they have a large quantity of personal belongings that they have brought with them from their previous home. The manager expressed the fact that it is important that this person has as much space as possible in their bedroom due to their limited mobility. We strongly agreed with this. Another person who moved into the home has had their bedroom decorated and been provided with a new carpet. However their chest of drawers were not functioning properly and need to be repaired by the maintenance man to ensure they are fit for use. The manager took action to resolve this problem on the day of the inspection. Therefore a requirement has not been made. The manager has ordered new sofas and new tables for the lounge and is waiting for them to be delivered. This will make the environment more homely. The manager is in the process of discussing the redecoration of the lounge, which now looks quite tired with the people who live in the home. We were pleased to see that a sensitive approach was being undertaken with regard to this matter as the people who live in the home had previously decorated the lounge themselves. The home has a reasonable size garden and the people in the home are making great efforts to make full use of this area by growing their own fruit and vegetables. This expands their opportunities and assists them to feel valued. We were informed by the manager and area manager that an application is going to be made for the current conservatory to be knocked down and this space to be extended to provided a computer/ games room. The manager has Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 20 ordered a computer to provide the people living in the home with the opportunity to access the Internet, which the home is waiting to be delivered. The manager informed us, that the bathrooms within the home are due for refurbishment and is going before the committee in August. We have asked that the proposed plan of action be forwarded to the commission. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by qualified staff, which improves the quality of life for the people living in the home. People are safeguarded by the homes recruitment policies and procedures. People living in the home are receiving regular supervision so a consistent approach to work can be maintained. EVIDENCE: The staffing rota was inspected and there were adequate numbers of staff on shift to meet the needs of the people living in the home on the day of the inspection. The staff had undertaken a range of training including violence and aggression, manual handling, infection control, health and safety, CosHH, first aid, fire safety, equality and diversity, food hygiene and protection of vulnerable adults. We were provided with evidence to indicate that staff had also been booked on future training sessions such as manual handling training on the 16th of July. This ensures that there is an ongoing training programme in place. This indicates that the development of the staff skills and knowledge is taken seriously. This improves the quality of care for people living in the home. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 22 Two staff had undertaken their NVQ level 2. Two staff has undertaken their NVQ level 3. One staff member is a qualified mental health nurse. The registered manager and has completed the registered managers award. This means that she has the necessary knowledge and skills to manage the home. The deputy manager is currently the acting manager in another home within the organisation. This is taking place while a new manager is recruited to this particular home. We have asked that we are kept up to date regarding this arrangement. We request that we are informed of the planned date for when the deputy manager returns to her current position or makes an application to be the manager of the home that she is working in. Staff recruitment policies and procedures and all relevant documentation were inspected and were found to be in order. This ensures that people are protected from potential abuse. The supervision records of staff indicated that staff are receiving regular supervision. This means that staff are being supported to work with the people living in the home in a consistent way. This improves people’s quality of life. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People are benefiting from a well run home. The manager is going to continue the monitoring review and assessment process that takes place within the home. The health and safety of the people living in the home is fully promoted and protected. EVIDENCE: People who live in the home do benefit from a well - run service. The manager is now the registered manager of the service. The manager has completed the registered managers award. The deputy manager of the home is currently the acting manager within one of the other homes within the organisation until the vacant post is recruited too. (Please see the staffing section.) Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 24 We looked at the provider visits on the day of the inspection. We are also being sent the regulation 37 notifications of incident forms. The liability insurance was seen and found to be in order. This means that staff working in the home are legally safeguarded if an injury or incident took place causing them harm. We inspected a range of health and safety documentation. Fire drills had taken place. However not all of the staff signatures identifying who had undertaken the fire were recorded on the fire drill document. The manager has agreed to ensure this takes place in future. The weekly bell tests were completed and the fire alarm system had been inspected to ensure it was working effectively. The emergency lighting had been checked regularly. The effectiveness of the fire door seals and the fire doors were being regularly checked. The manager is currently in the process of updating the fire risk assessment due to the particular needs of the people who have been newly accommodated in the home. The gas electric and water certificate were seen and found to be in order. This means that people’s health and safety is being protected in relation to these areas. The portable appliance- testing certificate had been sent to the property department. The manager contacted the office on the day of the inspection to request the report is sent to the home. The certificate is then going to be forwarded onto the commission. Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 15 Timescale for action The Registered Person must 15/07/08 ensure that a risk assessment is developed in relation to the identified person who can attempt to leaves his current home without the support of a staff member. This risk assessment must be linked to the persons care plan. This should identify and minimise any potential risk of harm to the person. The Registered Person must 10/08/08 ensure that the identified persons behaviour guidelines in relation to their potential aggressive outbursts are dated. All relevant professionals must agree the guidelines and their agreement must be evidenced. This will ensure that professional practice is followed. The Registered Person must 10/07/08 ensure that all activities are effectively recorded on the activity record. This must include when an activity has been declined and the action taken by staff to attempt to engage the person in the activity. This will DS0000010565.V366218.R01.S.doc Version 5.2 Page 27 Requirement 2. YA9 13 3. YA12 (16) (2) Linden Lodge 4. YA19 13 ensure that a clear record of activities is maintained. This will assist the manager to monitor the extent of the activities undertaken by the people living in the home. The Registered Person must 17/07/08 ensure that the list of staff signatures to indicate who can administer medication is accurate and up to date. This will ensure that clear procedures are in place in relation to who is qualified to administer medication. This will promote people’s health and wellbeing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA15 Good Practice Recommendations We strongly recommend that the record of people’s contact with their family and friends be logged on a specific contact sheet. This will assist the manager to monitor more effectively the level of contact between the people living in the home and their family and friends. We recommend that the record for recording the entry of people’s money in and out of their financial accounts must be fully accurate and the manager and line manager need to agree the most effective way of preventing recording errors. We request that the plan of the proposed refurbishment of the home is forwarded to the commission. 2. YA23 3. YA24 Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Linden Lodge DS0000010565.V366218.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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